TRAM / DIEP flap

 TRAM or DIEP Flap Procedure

Right mastectomy and immediate breast reconstruction with TRAM flapThis patient underwent a right mastectomy and her breast was immediately reconstructed with a pedicled TRAM flap.

In a TRAM or DIEP flap breast reconstruction skin, fat and muscle is taken from the lower abdominal wall and used to recreate the breast. This abdominal tissue is kept alive in one of two ways depending upon surgical preference.

1. The tissue can be kept connected to its blood supply and tunnelled into the breast. This is called a pedicled TRAM flap. Or alternatively...

2. The tissue can be completely removed, repositioned on the chest wall and its blood vessels reconnected to an artery and vein in the armpit or chest using microsurgery. This is called either a free TRAM flap or a DIEP flap.

In each case, the resulting wound in the abdominal wall is closed producing a similar effect to a  tummy tuck.

The procedure is carried out under a general anaesthetic and several drains are required in both the abdomen and the newly reconstructed breast. A catheter is usually placed in the bladder for 48 hours for patient comfort. Following the operation the patient is kept on bed rest and nursed in a very warm room for several days to encourage blood flow into the flap.

Postoperative pain is highly variable but in general the abdominal part of the operation is the more uncomfortable. Pain relief is usually given in the form of morphine for the first 48 hours, followed by strong painkilling tablets.

As a rough guide a TRAM flap breast reconstruction takes about 7 hours, requires 7 days in hospital and takes 7 weeks to recover from. The abdomen takes 7 months to regain near normal suppleness.

Advantages, Disadvantages and Possible Complications

Advantages

  • The tram flap provides a new breast of soft, warm, living tissue which will put on or lose weight with the rest of the patient and has the most natural appearance of all the breast reconstruction methods.
  • It enables a large breast to be reconstructed in a single operation
  • Avoids the disadvantages of a silicone prosthesis.
  • Additional advantage of a flatter abdomen.

Disadvantages

  • This reconstruction is a far bigger procedure than the original mastectomy and will be correspondingly more stressful. However, the benefits in terms of the new breast help to alleviate this.
  • Low mid-line abdominal scars may prevent the use of the TRAM flap due to damage to local blood vessels, which supply tissue required for transfer.

Possible Complications

  • Infection
  • Bleeding
  • Wound Healing Problems: This is seen particularly in patients who smoke
  • Flap Loss: One in 10 flaps undergoing a micro-surgical connection will develop some problem with the blood supply within 48 hours of surgery. These need to return to theatre in an attempt to restore the blood supply. One in twenty flaps fail completely.
  • Partial Flap Loss: This problem is mostly seen with those flaps which remain connected to their original blood supply and are tunneled into the new breast. It occurs in X% flaps.
  • Fat Necrosis: This can occurs in about 5% of cases as a result of inadequate blood supply to part of the flap. This results in the death of a portion of tissue which initially swells becoming painful and hard and eventually shrinks forming a hard scar within the breast.
  • Abdominal Hernia: The removal of part of the muscle of the abdominal wall results in some weakness there and an increased risk of bulging or hernias. This complication is seen about 5% of cases
  • Dog-Ears: Occasionally there will be small folds in the skin and fat at either end of the abdominal scar known as dog-ears which may require surgical excision or liposuction under local anaesthetic at a later date.

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